Background
In the right colon surgery, there is a growing literature comparing the safety of robotic right colectomy (RRC) to that of laparoscopic right colectomy (LRC). With this paper we aim to ...systematically revise and meta-analyze the latest comparative studies on these two minimally invasive procedures.
Methods
A systematic review of studies published from 2000 to 2017 in the PubMed, Scopus, and Embase databases was performed. Primary endpoints were postoperative morbidity and mortality. Secondary endpoints were blood loss, conversion to open surgery, harvested lymph node anastomotic leak, postoperative hemorrhage, abdominal abscess, postoperative ileus, time to first flatus, non-surgical complications, wound infections, hospital stay, and incisional hernia and costs. A subgroup analysis was performed on those series presenting only extracorporeal anastomosis in both arms.
Results
After screening 355 articles, 11 articles with a total of 8257 patients were eligible for inclusion. Operative time was found to be significantly shorter for the laparoscopic procedures in the pooled analysis (SMD − 0.99 95% CI − 1.4 to − 0.6,
p
< 0.001). Conversion to open surgery was more common during laparoscopic procedures than during the robotic ones (RR 1.7; 95% CI 1.1–2.6,
p
= 0.02). No significant differences in mortality (RR 0.47; 95% CI 0.18–1.23,
p
= 0.124) and postoperative complications (RR 1.05; 95% CI 0.9–1.2,
p
= 0.5) were found between LRC versus RRC. The pooled mean time to first flatus was higher in the laparoscopic group (SMD 0.85 days; 95% CI 0.16–1.54,
p
= 0.016). Hospital costs were significantly higher in RRCs (SMD − 0.52; 95% CI − 0.52 to − 0.04,
p
= 0.035).
Conclusions
RRC can be regarded as a feasible and safe technique. Its superiority in terms of postoperative recovery must be confirmed by further large prospective series comparing RRC and LRC performed with the same anastomotic technique. RRC seemed to be associated with higher costs than LRC.
Background
The aim of this study is to report the experience with conversion surgery from six Gruppo Italiano Ricerca Cancro Gastrico (GIRCG) centers, focusing our analysis on factors affecting ...survival and the risk of recurrence.
Methods
A retrospective, multicenter cohort study was performed in patients who had undergone conversion gastrectomy between 2005 and 2017. Data were extracted from a GIRCG database including all metastatic gastric cancer patients submitted to surgery. Only stage IV unresectable tumors/metastases which became resectable after chemotherapy were included in this analysis.
Results
Forty-five resected M1 patients were included in the analysis. Reasons for being deemed unresectable at diagnosis were peritoneal involvement (PCI > 6) (
n
= 38, 84.4%), distant metastatic nodes (
n
= 3, 6.6%) and extensive liver involvement (
n
= 4, 8.8%). Median follow-up was 25 months (IQR 9-50). Median overall survival from surgery was 15 months and 1-, 3- and 5-year survivals were 57.2, 36.1 and 24%, respectively. Median progression-free survival was 12 months with 1- and 3-year survival of 46.4 and 33.9%, respectively. At cox regression analysis the only independent prognostic factor for OS was the presence of more than one type of metastasis (HR 4.41, 95% CI 1.72–11.3,
p
= 0.002). A positive microscopic resection margin was the only risk factor for recurrence (HR 5.72, 95% CI 1.04–31.4,
p
= 0.045).
Conclusions
Unresectable stage IV GC patients could benefit from radical surgery after chemotherapy and achieve long survivals. The main prognostic factor for these patients was the presence of more than one type of extra-gastric metastatic involvement.
Background
This study aimed to review the new evidence to understand whether the robotic approach could find some clear indication also in left colectomy.
Methods
A systematic review of studies ...published from 2004 to 2022 in the Web of Science, PubMed, and Scopus databases and comparing laparoscopic (LLC) and robotic left colectomy (RLC) was performed. All comparative studies evaluating robotic left colectomy (RLC) versus laparoscopic (LLC) left colectomy with at least 20 patients in the robotic arm were included. Abstract, editorials, and reviews were excluded. The Newcastle–Ottawa Scale for cohort studies was used to assess the methodological quality. The random-effect model was used to calculate pooled effect estimates.
Results
Among the 139 articles identified, 11 were eligible, with a total of 52,589 patients (RLC,
n
= 13,506 versus LLC,
n
= 39,083). The rate of conversion to open surgery was lower for robotic procedures (RR 0.5, 0.5–0.6;
p
< 0.001). Operative time was longer for the robotic procedures in the pooled analysis (WMD 39.1, 17.3–60.9,
p
= 0.002). Overall complications (RR 0.9, 0.8–0.9,
p
< 0.001), anastomotic leaks (RR 0.7, 0.7–0.8;
p
< 0.001), and superficial wound infection (RR 3.1, 2.8–3.4;
p
< 0.001) were less common after RLC. There were no significant differences in mortality (RR 1.1; 0.8–1.6,
p
= 0.124). There were no differences between RLC and LLC with regards to postoperative variables in the subgroup analysis on malignancies.
Conclusions
Robotic left colectomy requires less conversion to open surgery than the standard laparoscopic approach. Postoperative morbidity rates seemed to be lower during RLC, but this was not confirmed in the procedures performed for malignancies.
Purpose
Intrahepatic cholangiocarcinoma (ICC) has a poor prognosis, when unresectable; therefore, intra-arterial therapies (IAT) such as trans-arterial chemoembolization (TACE) and trans-arterial ...radioembolization (TARE) have been employed. With the present systematic review and meta-analysis, we aimed to analyse published studies to understand if one IAT can be superior to the alternative.
Materials and methods
A systematic search of PubMed and Web of Science databases was performed for articles published until 1 March 2020 relevant to IAT for ICC. Overall survival was the primary end point. Occurrence of clinical adverse events and tumour overall response were secondary outcome measures.
Results
A total of 31 articles (of 793, n.1695 patients) were selected for data extraction, 13 were on TACE (906 patients) and 18 were on TARE (789 patients). Clinical and tumour characteristics showed moderate heterogeneity between the two groups. The median survival after TACE was 14.2 months while after TARE was 13.5 months (95%C.I.: 11.4–16.1). The survival difference was small (
d
= 0.112) at 1 year and negligible at 2 years (
d
= 0.028) and at 3 years (
d
= 0.049). The radiological objective response after TACE was 20.6% and after TARE was 19.3% (
d
= 0.032). Clinical adverse events occurred in 58.5% after TACE, more frequently than after TARE (43.0%,
d
= 0.314).
Conclusion
In conclusion, IATs are promising treatments for improving outcomes for patients with unresectable ICC. To date, TACE and TARE provide similar good outcomes, except for adverse events. Therefore, the decision about techniques is determined by ability to utilize these resources and patient specific factors (liver function or lesion dimension).
Advanced unresectable gastric cancer has a dismal prognosis. The aim of this study was to evaluate the short- and long-term outcomes of patients who underwent induction chemotherapy ± gastrectomy for ...advanced gastric cancer.
All patients referred to our center with a clinical diagnosis of unresectable locally advanced or stage IV gastric adenocarcinoma between April 2005 and August 2016 were included in the study. Cox regression was performed to find independent prognostic factor among the considered variable.
The cohort included 73 patients: 16 had best supportive care, 35 chemotherapy alone and 22 chemotherapy plus radical surgery. Thirty-three patients underwent surgery after chemotherapy. Twenty-two patients had R0 surgery, while the remaining 11 had only an exploratory procedure. Nine patients (40.9%) underwent gastrectomy plus hyperthermic intraperitoneal chemotherapy. Three patients out of 22 developed postoperative complications with a Clavien-Dindo grade above 2. Median survival was 50 months for patients who had chemotherapy plus surgery while it was 14 and 3 for those who had chemotherapy alone and best supportive care, respectively (p < 0.0001). Cox regression analysis performed on the whole cohort identified only radical conversion surgery as an independent factor positively associated with survival (HR 0.12, 95% CI 0.05–0.29, p < 0.0001).
Conversion gastrectomy, when R0 could be achieved, is associated with long survivals and it is the most important prognostic factor in patients with advanced gastric cancer. Further studies are needed to define the ideal patient who can really benefit from this treatment.
•Unresectable gastric cancer could be associated with a dismal prognosis.•Chemotherapy has offered new perspectives for these patients.•Conversion surgery may offer good survivals after palliative chemotherapy.•Surgery should not be excluded a priori in advanced cases.
Background
Early Gastric Cancer (EGC) reaches 25% of the gastric cancers surgically treated in some areas of Northeastern Italy and is usually characterized by a good prognosis. However, among EGCs ...classified according to Kodama’s criteria, Pen A subgroup is characterized by extensive submucosal invasion, lymph node metastases and worse prognosis, whereas Pen B subgroup by better prognosis. The aim of the study was to characterize the differences between Pen A, Pen B and locally advanced gastric cancer (T3N0) in order to identify biomarkers involved in aggressiveness and clinical outcome.
Methods
We selected 33 Pen A, 34 Pen B and 20 T3N0 tumors and performed immunohistochemistry of mucins, copy number variation analysis of a gene panel, microsatellite instability (MSI),
TP53
mutation and loss of heterozygosity (LOH) analyses.
Results
Pen A subgroup was characterized by MUC6 overexpression (
p
= 0.021). Otherwise, the Pen B subgroup was significantly associated with the amplification of
GATA6
gene (
p
= 0.002). The higher percentage of MSI tumors was observed in T3N0 group (
p
= 0.002), but no significant differences between EGC types were found. Finally,
TP53
gene analysis showed that 32.8% of Pen tumors have a mutation in exons 5–8 and 50.0% presented LOH. Co-occurrence of
TP53
mutation and LOH mainly characterized Pen A tumors (
p
= 0.022).
Conclusions
Our analyses revealed that clinico-pathological parameters, microsatellite status and frequency of
TP53
mutations do not seem to distinguish Pen subgroups. Conversely, the amplification of
GATA6
was associated with Pen B, as well as the overexpression of MUC6 and the
TP53
mut/LOH
significantly characterized Pen A.
It has been previously demonstrated that T lymphocytes may be involved in the development of hypertension and microvascular remodeling, and that circulating T effector lymphocytes may be increased in ...hypertension. In particular, Th1 and Th 17 lymphocytes may contribute to the progression of hypertension and microvascular damage while T-regulatory (Treg) lymphocytes seem to be protective in this regard. However, no data is available about patients with severe obesity, in which pronounced microvascular alterations were observed.
We have investigated 32 severely obese patients undergoing bariatric surgery, as well as 24 normotensive lean subjects and 12 hypertensive lean subjects undergoing an elective surgical intervention. A peripheral blood sample was obtained before surgery for assessment of CD4+ T lymphocyte subpopulations. Lymphocyte phenotype was evaluated by flow cytometry in order to assess T-effector and Treg lymphocytes.
A marked reduction of several Treg subpopulations was observed in obese patients compared with controls, together with an increased in CD4+ effector memory T-effector cells.
In severely obese patients, Treg lymphocytes are clearly reduced and CD4+ effector memory cells are increased. It may be hypothesized that they might contribute to the development of marked microvascular alterations previously observed in these patients.
After the REGATTA trial, patients with stage IV gastric cancer could only benefit from chemotherapy (CHT). However, some of these patients may respond extraordinarily to palliative chemotherapy, ...converting their disease to a radically operable stage. We present a single centre experience in treating peritoneal carcinomatosis from gastric cancer.
All patients with stage IV gastric cancer with peritoneal metastases as a single metastatic site operated at a single centre between 2005 and 2020 were included. Cases were grouped according to the treatment received.
A total of 118 patients were considered, 46 were submitted to palliative gastrectomy (11 were considered M1 because of an unsuspected positive peritoneal cytology), and 20 were submitted to Hyperthermic Intraperitoneal Chemotherapy (HIPEC) because of a <6 Peritoneal Cancer Index (PCI). The median overall survival (OS) after surgery plus HIPEC was 46.7 (95% CI 15.8-64.0). Surgery (without HIPEC) after CHT presented a median OS 14.4 (8.2-26.8) and after upfront surgery 14.7 (10.9-21.1). Patients treated with upfront surgery and considered M1 only because of a positive cytology, had a median OS of 29.2 (25.2-29.2). The OS of patients treated with surgery plus HIPEC were 60.4 months (9.2-60.4) in completely regressed cancer after chemotherapy and 31.2 (15.8-64.0) in those partially regressed (
= 0.742).
Conversion surgery for peritoneal carcinomatosis from gastric cancer was associated with long survival and it should always be taken into consideration in this group of patients.
Rectal cancer presents a significant burden globally, often requiring multimodal therapy for locally advanced cases. Long-course chemoradiotherapy (LCRT) and short-course radiotherapy (SCRT) followed ...by surgery have been conventional neoadjuvant approaches. Recent trials favor LCRT due to improved local control. However, distant tumor recurrence remains a concern, prompting the exploration of total neoadjuvant therapy (TNT) as a comprehensive treatment strategy. Immune checkpoint inhibitors (ICIs) show promise, particularly in mismatch repair-deficient (dMMR) or microsatellite instability-high (MSI-H) tumors, potentially revolutionizing neoadjuvant regimens. Nonoperative management (NOM) represents a viable alternative post-neoadjuvant therapy for selected patients achieving complete clinical response (cCR). Additionally, monitoring minimal residual disease (MRD) using circulating tumor DNA (ctDNA) emerges as a non-invasive method for the assessment of treatment response. This review synthesizes current evidence on TNT, ICIs, NOM, and ctDNA, elucidating their implications for rectal cancer management and highlighting avenues for future research and clinical application.
Sorafenib is the only approved drug in first-line treatment for hepatocellular carcinoma. Recently, the Phase III REFLECT trial proved lenvatinib not inferior to sorafenib, potentially establishing a ...new standard of care in this setting. The study showed that both have similar overall survivals, yet with longer time to progression for lenvatinib. Currently, the selection of one or other is not based on clinical or biological parameters for this reason we performed a network meta-analysis and we also analyzed the REFLECT trial and its implications in the current and future clinical practice.
We performed the meta-analysis according to the Prisma statement recommendations. HR was the measure of association for time to progression and overall survival. The pooled analysis of HR was performed using a random effect model, fixing a 5% error as index of statistical significance.
For HBV-positive patients, there was a clear trend in favor of lenvatinib over sorafenib (HR 0.82 95% credible interval CrI 0.60-1.15). For HCV-positive no differences between lenvatinib and sorafenib were observed (HR 0.91 95% CrI 0.41-2.01). The data showed that lenvatinib could be the best drug for HBV-positive patients in 59% of cases compared to only 1% of patients treated with sorafenib.
The identification of clinical or biological markers that could predict response or resistance to treatments is needed to guide treatment decision. This network meta-analysis demonstrates that the etiology is a good candidate and this result should be validated in a specific trial.
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